Acute (not on Repeat) Prescription Request Form

Please only use this form to request 'one-off medications' you have been prescribed before and hospital recommendations.

Your request will be subject to a doctors evaluation and / or hospital documentation. You may require an appointment or telephone consultation before we are able to authorise and prescribe your request.

THE FOLLOWING MEDICATIONS WILL NOT BE PRESCRIBED WITHOUT SEEING OR SPEAKING TO A DOCTOR FIRST FOR
SAFETY REASONS.

ALL ANTIBIOTICS
ALL ANTIDEPRESSANTS
CONTROLLED DRUGS
SLEEPING TABLETS
PAIN PATCHES
ALL STRONG PAINKILLERS

Please request a triage appointment if you require any of the above medications.

Name

Date Of Birth

Address

Telephone Number

Email Address

Drug Name

Drug Strength (e.g. 5mg)

Daily Dose (e.g. 1 tablet at night)

Reason for medication request

If you have been provided a 'Discharge Medication Summary' by the hospital, please upload the form using the file attachment button below

Which chemist would you like to collect from?

Please allow 48 hours before collecting from the local pharmacy.